An 83-year-old woman was referred to our hospital due to diverticular bleeding of the colon. She had a history of everolimus-eluting stent implantation in the left anterior descending artery (31 months before) and the right coronary artery (20 and 31 months before) because of stable angina. She was prescribed aspirin 100 mg/day and clopidogrel 75 mg/day, followed by single antiplatelet therapy by aspirin during the last 8 months. Aspirin was discontinued for the endoscopic therapy at her admission. Complete blood count showed hemoglobin of 17.5 g/dl and hematocrit of 55.2%, from which polycythemia vera (PV) was suspected. Three days after admission, she died of sudden cardiac arrest. Autopsy revealed the cause of her death to be pulmonary thromboembolism. PV was confirmed by bone marrow examination. Ex vivo optical coherence tomography (St. Jude Medical, St. Paul, Minnesota) and pathology of coronary arteries were examined. Optical coherence tomography illustrated neointima with high-intensity signal and irregular luminal surface (Figure 1A). A signal-rich, slit-like structure (Figure 1B) with microchannels (Figure 1C) suggested thrombus formation. Corresponding histology revealed neointima composed of granulation tissue (Figures 1D and 1G). Organized fibrin thrombi (Figures 1E and 1H) and capillaries (Figures 1F and 1I) were also identified.

Increased hematocrit levels and vascular inflammation are the intrinsic risks of thrombosis in the PV patient (1–3). The current case presented in-stent restenosis with extensive inflammation, which might be associated with PV. The strategy for coronary intervention in PV patients should be deliberate due to their high thrombogenic risk.

Footnotes

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.